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November 6, 2014 Newsletter Archive

Watch Us Grow:
We are Pleased to Introduce Denise A. Clark

Mark and Daphne are pleased that Denise A. Clark has become associated with our firm. Denise has been providing legal counsel and education for over 20 years. She focuses her practice in the areas of estate planning, elder law and long term care planning, guardianship and probate. In addition, Denise's unique qualifications expand past the law to include her licensure as a registered pharmacist. This combination of education and experience enables Denise to understand, assist and advise clients on a number of emotional and complicated medical/legal issues including all areas of long term care planning and obtaining long term care services.

Denise has lectured before professionals and laypersons on estate planning, elder law and probate issues. She is admitted to practice in Vermont, Maryland, and the District of Columbia, and is a member of the National Academy of Elder Law Attorneys, the Vermont Chapter of the National Academy of Elder Law Attorneys and the Vermont Bar Association.

Denise earned her B.S. degree in Pharmacy from the University of North Carolina at Chapel Hill and is a registered pharmacist in North Carolina and Vermont. She earned her J.D. degree from Wake Forest University School of Law.

COMMUNITY INVOLVEMENT

In addition to being a seasoned elder law attorney, Denise is deeply involved in her community including serving on the Board of Directors of the Rutland Downtown Partnership, Board of Directors at Vermont Achievement Center, Mendon School Board, Barstow School Board, Rutland Northeast Supervisory Union Board, Executive Committee of the Rutland Northeast Supervisory Union Board, Board of Directors of the Vermont Pharmacy Association, Committee Member of the Governor's Health Care Workforce Committee and Pico Ski Club Member.

Matters of Living: Moving the Conversation Between Doctor and Patient Beyond Treatment and End of Life Care

by Daphne Moritz

This week for many of us, Brittany Maynard has been on our minds. If you do not know her story, she is the 29 year old who received a terminal brain cancer diagnosis earlier this year, and chose to move to Oregon, a state which has a death with dignity law, so she could terminate her life when she chose. She chose last Sunday.

Affable, attractive and youthful, Ms. Maynard became an outspoken advocate for the option of expanding death with dignity statutes to other states, and she had a lot of supporters and a lot of press. Ms. Maynard also had her detractors, including Dartmouth Hitchcock Memorial Hospital affiliated, and palliative care specialist, Dr. Ira Byock. Byock's points, however, do not merely react to doctor assisted death. They reflect what seems to be the elephant in the room, the aspect of receiving a diagnosis that we do not discuss. We do not discuss what it means to have a dignified death, and perhaps more importantly, we fail to address what the run up to that death actually looks like in America.

What seems to be happening is that we tend to focus a great deal on the very end of life, but we do not always remember to discuss that middle ground - how to live well, with the quality of life and the dignity that is personal to us all, from the time we recognize our diagnosis until the end. However, some people are seeking to shift that conversation.

In his latest work, Being Mortal: Medicine and What Matters in The End, Harvard surgeon, Atul Gawande, seeks to change the country's approach to aging and dying.

Though Gawande had been discussing his own patients' health care issues for years, he realized that he was spending so much of his life in the hospital but paying scant attention to palliative care, hospice, and patient informed decisions regarding end of life matters.

In an interview on The Diane Rehm Show which aired October 6, 2014, Gawande stated that medicine has always been concerned about our health and safety, yet we have not necessarily focused on a good death. There is not often a discussion about whether aggressive treatment is necessary or a good thing, and there may be goals much bigger than just having the patient living longer. These are personal but they have to be probed.

Gawande went on to argue that many surgeons and other specialists are able to talk to patients about the course of treatment but few are really able to counsel their patients about the various issues. Counseling more deeply on the nature of so called life prolonging treatments versus less invasive forms of care over the course of several months or even several years prior to death, is at the cornerstone of the change Gawande would like to see. We already have evidence that being able to spend time at home, maintaining a social life, and managing pain, allow patients to maintain some sort of quality of life even if their life is shortened due to not taking aggressive treatment measures.

However, there remains in many cases, a long slide to death - for example, when one becomes unresponsive. There also remains a question of whether medical professionals are following advance directives. Additionally, there are concerns about potential narrowing of quality of life among patients who are in institutionalized care with family and strong advocates living far away. Making sure that both professionals and family members understand an individual's priorities and goals after a terminal diagnosis may help in these instances.

We ought to remember too that in large part, we all are on the long march toward dying. It behooves all of us to understand the aging process - what changes do we undergo in ourselves as we age? And doctors must learn to ask people the right questions such as what is your understanding of your health, what are your fears and understanding of the future, what are your goals, what are the tradeoffs you are willing to make?

With end of life care, meeting with palliative specialists may make the difference. The challenge remains the disconnect from medical specialists. Not that long ago, an oncology resident came into our office for some planning. I took the time to ask him about his diagnosis, treatment and end of life discussions with his patients and his answer was that his hospital had a great palliative care department. It seems some doctors, namely those involved in aggressively treating patients, are still allowed a "pass" on these difficult conversations. Yet, sometimes a person's primary care physician, their family and the palliative care specialist know what the patient's priorities and goals are, and still there remains a disconnect with the specialist or specialists involved.

A challenge is that specialists can sometimes make it difficult for a comprehensive plan. Sometimes it seems like a medical project manager could be useful. A dilemma among the profession is that surgeons and other specialists are often trained to keep the patient alive as long as possible, but here lies the rub. Often, this is a goal that is in direct conflict with a patient's own goals and priorities. The question a patient ought to be asked by every doctor is "what would a life worth living look like to you?" In many cases the relationship between the doctor and patient is fractured, and we must work on enhancing it to move in the direction which truly and clearly helps inform the patient's care and quality of life decisions.

And all of this brings us back to Death with Dignity and whether this will this become more prevalent after Brittany Maynard's story. Even Gawande, who seems to support a well regulated death with dignity law, says that we have to be cautious that we do not focus too heavily on a good death, versus a good life all the way to the end. We have to be mindful not to just focus on the patient assisted death to the exclusion of palliative and hospice care. However, each individual is unique in his or her priorities, beliefs and goals. At the end of the day, the current objective is to seek to have doctors listen to and learn each patient's story and provide the patient with counseling that includes more than providing medical treatment, but helping patients live as well as they can, within the constructs of choices a patient makes, based on the patient's values and wishes.

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